Palmar Burns Research Articles

Cutaneous functional units prediction in outcomes of early and intensive splinting following palmar burn injury in young children: a prospective study

BackgroundPalmar burn injuries are common in young children and can result in contracture. MethodsA prospective longitudinal study describes outcomes of palm and digit extension splint use following burn in 75 children (83 hands) aged < 5 years and determines whether specific cutaneous functional units (CFUs) are associated with early signs of contracture (ESC). Outcomes were assessed up to 9–18 months following burn. Routine clinical data was collected at therapy reviews. ResultsChildren were splinted > 12 h/day for a mean of 158 days following burn. The mean time to splint cessation was 264 days following burn. Fourteen hands developed ESC (17%): 12 hands had full ROM restored following conservative management, 2 hands (3%) progressed to contracture. Hands that developed ESC had greater healing time (p = 0.002), greater number of CFUs affected (p < 0.001), and greater number of immediate first webspace and extended first webspace CFUs affected (p = 0.002, p < 0.001 respectively). ESC risk increases for each day to heal (odds ratio [OR] 1.1, 95% CI 1.0–1.2) and each CFU in extended first webspace (OR 2.8, 95% CI 1.5–5.0). ConclusionEarly and intensive splinting following palmar burn results in excellent ROM. Burns involving more CFUs or the first webspace are associated with ESC.

Parent perspective of an intensive splinting intervention following palmar burn injury in young children

BackgroundParents may experience challenges implementing their child’s therapeutic treatment following burn. MethodsA mixed methods study was conducted to explore the parent experience of intensive splinting following palmar burns in young children (median age 16 months [IQR 14]). Thirteen parents were interviewed after cessation of their child’s splinting (mean 12 months [SD 2] following burn). Parent interviews were semi-structured with open-ended questions and conducted one-to-one. Inductive thematic analysis was completed by two researchers with consensus achieved through discussion and agreement from third researcher. Themes were triangulated with quantitative data, including range of motion (ROM), scar, developmental and quality of life outcomes. ResultsChildren used the splint intensively (>12–24 h/day) for median 179 days (IQR 74) with all splinting ceased by median 275 days (IQR 105). All children had full ROM at scar maturation. Thematic analysis revealed two main themes: parents perceive the impact of splinting to be greater on them than their child and parents perceive outcomes to be more important than burden. Parents described the importance of routine and therapeutic relationships in ongoing engagement with intervention. ConclusionParents consider intensive splinting to impact them more than their child with burden of care manageable considering overall outcomes.

Z-plasty in post-burn contracture of hand among pediatric patients.

Objective: To find out the frequency of hand burn and the effectiveness of Z-plasty in post-burn hand contractures. Study Design: Descriptive Cross-sectional study. Setting: Department of Pediatric Surgery, Khawaja Muhammad Safdar Medical College, Sialkot. Period: January to December 2021. Material &amp; Methods: A preformed proforma was used, consisting of 4 parts, the first part including demographic data like age and gender, second part consist of patient’s history, consisting of presenting complaint, its duration, past history of any medical or surgical illness or comorbidity. Third part consisted of physical clinical examination of the hand (fingers and palm) while fourth part was for post-operative complications of reconstructive procedure, Z-plasty. The data was analyzed by using Statistical Package for Social Sciences (SPSS) version-20. Results: The most commonly affected age group was less than 6 years of majority of them, 53.3%, were male. The most common cause was thermal burns as compared to electrical burns. Among 91.1% of the participants, the right hand was affected more. Majority of the cases (48.9%) reported single finger burn, followed by multiple fingers (31.1%) and very few (20%) were having palm burns. Segregating the single figure, results showed that little finger was affected in 20% of cases No post-operative complications, like skin necrosis, wound dehiscence, hematoma or infection, were noted. Conclusion: It can be concluded that post-burn hand contractures and hand deformity was common among children. Z-plasty with/without skin grafting is an ideal surgical management to subside the contracture of hand.

Reliability, Validity, and Predictive Validity of Cutaneous Functional Units Predicted to Scar Following Palmar Burn Injury in Young Children.

Identification of children at risk of palmar burn scar is important for early initiation of scar management. This study determined the interrater reliability of face-to-face and photographic assessments of 29 palmar cutaneous functional units (CFUs) predicted to scar following palmar burn. The validity of photographic compared to face-to-face assessment, and the predictive validity of both assessment types to identify scarring at 3 to 6 months following burn, was also established. Thirty-nine children (40 hands) post burn injury were assessed face-to-face in the clinical setting, following healing of their palmar burn, by three burn therapists. Photographs of the children's hands at initial assessment were assessed by the same therapists a minimum of 6 months later. To determine which CFUs scarred, children were reassessed face-to-face in the clinical setting 3 to 6 months following their burn. For analysis, 29 CFUs were merged into eight separate groups to determine the number of CFUs predicted to scar per CFU group for face-to-face and photographic assessments. The range of agreement for individual CFUs within CFU groups was also calculated for both assessment types. Excellent interrater reliability was established for face-to-face assessment in all eight CFU groups (ICC2,1 0.83-0.96). Photographic assessment demonstrated good to excellent interrater reliability in six CFU groups (ICC2,1 0.69-0.90) and validity in seven CFU groups (ICC2,1 0.66-0.87). Good to excellent predictive validity was established for both assessment types in seven CFU groups (face-to-face ICC2,1 0.60-0.95, photographic ICC2,1 0.69-0.89). Experienced therapists can reliably assess CFUs face-to-face or via photographs and predict future scar development.

Reliability of a novel technique to assess palmar contracture in young children with unilateral hand injuries

BackgroundPalmar contracture in young children can have significant developmental consequences. Despite this, objective techniques to measure palmar range of movement and quantify contracture in young children are limited. PurposeThe purpose of this study was to determine the reliability of hand span and hand length measures in young children and to establish whether there is any association with age, sex and presence of a palmar burn injury in the reliability of these measures. The study also sought to determine the normative difference and establish a cut off value for the between-hand difference to identify loss of movement in 1 hand. Study designCross sectional MethodsForty-four children aged 0 to <5 years were recruited. Twenty-two children had a unilateral palmar burn injury and 22 did not have a palmar burn injury. Each child's hand span and hand length were measured 3 times. This was performed twice by the first assessor and once by the second assessor. Intraclass correlation coefficients were calculated to determine the intra-rater and inter-rater reliability. The largest of the 3 values for both hand span and hand length from the first assessor's first assessment were used to determine the normative between-hand difference. Outliers were removed prior to determining the normative difference. Children were considered outliers if their between-hand difference in hand span and/or hand length was in the top 5% of values. ResultsExcellent reliability was established for hand span and hand length measures for the whole group (intra-rater ICC2,1 ≥0.95, inter-rater ICC2,1 ≥0.94). The mean normative between-hand difference for both measures was 2 mm. The cut-off for the normative difference in hand span was <9 mm and hand length was <6 mm. ConclusionThis measurement technique has excellent reliability and could be a useful method to quantify palmar range of movement and identify contracture in young children with unilateral hand injuries.

Prise en charge des séquelles de brûlure palmaire chez l’enfant, à propos de 49 cas

Even if they represent only 2.5% of the total body surface area, the hands are burnt in 50% of hospitalized patients. The risk of sequelae is significant, especially in children, human being in full growth, and a source of aesthetic and functional handicap. The aim of this study is to research the predictive factors of sequelae, to study their treatment of and their evolution. We included children under six years of age with deep palmar burns of the hand between 1998and 2008. Demographics, characteristics of the initial burn and its treatment were noted. Then, we studied the types of hand burn sequelae and their treatment. Finally, we observed their evolution over time with an aesthetic and functional evaluation and their impact on quality of life. Forty-nine children, representing 70hands, were included in the study. The mean age at the time of the initial burn was 16.2months (6; 60). The initial treatment was directed healing in 39% of cases and thin skin excision-grafting in 61% of cases. The type of sequelae most represented was bridle in 73% of cases. Treatment consisted of rehabilitation measures (13%) or surgery (69%). The mean age at the time of surgery was 10.1years (4; 19). These were plasties (62%), total skin grafts (15%) or a combination of both (23%). The current follow-up is 16.2years. The aesthetic result is considered good in 52% of cases, the functional result is good in 78% of cases. The impact on the quality of life is low and the parents are satisfied with the initial care. The treatment of the sequelae of burnt hands gives good results but involves well-conducted rehabilitation and regular monitoring. The treatment period must be adapted and the surgery simple, effective and specific to the type of sequelae.

Outcomes of Early and Intensive Use of a Palm and Digit Extension Orthosis in Young Children After Burn Injury.

Burns to the palmar aspect of the hand are prevalent in young children. The development of scar tissue across the flexor surface of the hand combined with the years of growth ahead may result in considerable complications. This study was undertaken to describe outcomes of early and intensive use of a palm and digit extension orthosis with the elbow immobilized at 90° flexion following a palmar hand burn. A retrospective review of 107 children (mean age 18 months [SD 10]) treated at a statewide Pediatric Burns Unit from 2012 to 2016 was performed. Three children (3%) developed contracture during the 24-month study follow-up period. The other 104 children (97%) had full ROM at 24 months or at either the point of discharge or loss to follow-up. Early signs of contracture, defined as loss of full movement or significant banding, developed in 26 children (24%) in the first 9 months after burn. With intensive physiotherapy, 23 children regained full movement by 12 months after burn. Children who did not achieve complete wound healing at 1 month after burn and children with hypertrophic scarring at 2 months after burn were significantly more represented among cases of early signs of contracture (P = .013). When undertaken with regular clinical review, early and intensive use of a palm and digit extension orthosis can maintain full extension of the palm and digits in children after palmar burn.

Skin grafting after paediatric palmar burns: an analysis of 82 patients.

Contact burn injuries to the palm are common in toddlers. We report a case series of 82 paediatric patients (age 7-48 months) with contact burn injury of the palm. We share our experience and outcomes of using plantar split-thickness skin grafts for resurfacing of the paediatric palm. We found that despite the excellent colour and texture match, split-thickness skin grafts from glabrous skin during growth are prone to motion-limiting scare contracture. From this series, we conclude that full-thickness skin grafts remain the reference standard of care in paediatric patients' hands. We recommend that children with burn scars should have regular check-up examinations until they are fully grown. Level of evidence: IV.

Is there any place for spontaneous healing in deep palmar burn of the child?

Child palm burns arise by contact and are often deep. The singular difficulty of such a disease comes from the necessity of the child growth and from the potential occurrence of constricted scars. In order to avoid sequelae, the actual gold standard is to practice an early excision of the burn, followed by a skin graft. The aim of this study is to evaluate the results of spontaneous healing combined with rehabilitation versus early skin grafting and rehabilitation concerning the apparition of sequelae. We performed a retrospective study in two burn centers and one rehabilitation hospital between 1995 and 2010. Eighty-seven hands have been included in two groups: one group for spontaneous healing and the other group for excision and skin grafting. Every child benefited from a specific rehabilitation protocol. The two main evaluation criteria were the duration of permanent splint wearing and the number of reconstructive surgery for each child. The median follow-up duration is about four years. The two groups were comparable. For the early skin grafting group, the splint wearing duration was 1/3 longer than for the spontaneous healing group. Concerning the reconstructive surgery, half of the grafted hands needed at least one procedure versus 1/5 of spontaneous healing hands. Our results show the interest of spontaneous healing in palmar burn in child, this observation requires a specific and intense rehabilitation protocol.

Effectiveness of basic fibroblast growth factor for pediatric hand burns

Aim of the studyPediatric hand deep dermal and deep burns may lead to serious hand deformity with functional impairment and result in an esthetically unfavorable outcome. Since there is no guideline regarding the use of growth factors for pediatric hand burns, we sought to investigate the effectiveness of an angiogenic and regenerative growth factor, basic fibroblast growth factor (bFGF). MethodsConsecutive series of second degree or third degree palmer burns at less than 3 years of age seen from January 2010 to June 2014 were included for evaluation at 6 months post-wound healing. The bFGF treatment started from just after injury and continued up to 21 days. Each patient had their scars scored using the Vancouver Scar Scale (VSS) at 6 months after wound healing. ResultsThere were 34 children with 49 acute palmar burns. The mean healing period was 13.5 ± 4.3 days (7–44 days) and 43 wounds healed within 21 days. There was no need of additional surgery in the 43 wounds, healed within 21 days. In comparison to the wounds for which healing took more than 21 days, the wounds that healed within 21 days demonstrated significantly better pigmentation, pliability, and height according to the VSS (p < 0.05), as well as no scar contracture or hypertrophic scars. ConclusionbFGF treatment was effective in cases that healed within 21 days, avoiding scar contractures and hypertrophic scars. Our methods using bFGF to complete wound healing are less invasive and produce better results in pediatric palmer burns.

The Use of Glabrous Skins Grafts in the Treatment of Pediatric Palmar Hand Burns

An often overlooked, yet useful, technique in the treatment of palmar hand burns is the use of glabrous skin grafting, particularly in dark-skinned individuals. Pediatric palmar burns are a particularly unique subset of burns. The typical split-thickness or full-thickness skin grafts leave a notably different skin texture and pigmentation. It is also known that the psychological aspects of a pediatric burn can be quite burdensome for a child as he or she progresses through childhood and adolescence. For a dark-skinned patient the placement a standard full-thickness skin graft in a nonpigmented palm provides for a constant reminder of a traumatic event. We report a case series of pediatric patients who were managed with glabrous skin grafting from the plantar aspect of the foot. A retrospective review of palmar skin burns requiring grafting at a single pediatric burn center experience over a 2 and a half year time period was performed. Seventeen patients were identified. Our treatment algorithm for deep partial thickness burns first relies on a combination of operative and nonoperative measures to expedite the demarcation of the burn injury. If the burn is full thickness in nature or if a lack of progression of healing is identified within the first 14 days of injury, then skin grafting is recommended. Our technique for performing the graft is described. The average age at time of surgery was 2.05 years (6 months to 6.8 years). Fourteen of the 17 patients had darker skin types (Fitzpatrick Type III-VI) and identified themselves as either Hispanic or African American. The average size of the area requiring skin graft after debridement was 0.94% total body surface area (0.5%-2.0%). Of the patients that were not lost to follow-up, 1 patient required additional grafting after developing a finger contracture for splint noncompliance. Aesthetically, the wounds went on to heal with an excellent pigment match and an inconspicuous donor site. In the management of deep-partial or full-thickness palmar skin burns in the pediatric population that require grafting, the use of plantar glabrous skin grafts offers a reliable option for coverage. The aesthetic and functional results are improved over standard techniques.

Functional and Cosmetic Outcome of Full- Versus Split-Thickness Skin Grafts in Pediatric Palmar Surface Burns

Palmar hand burns continue to be a common injury in the pediatric population, with long-term implications for function, hand rehabilitation, and psychosocial well-being in a growing child. Debate over the choice of full-thickness skin grafts (FTSG) and split skin grafts (SSG) for optimal subsequent functional and cosmetic outcomes continues. This study prospectively evaluated children who required skin grafting of palmar burns at our institution between January 2008 and December 2009. A clinical assessment of the grafted area and donor site using the Vancouver Scar Scale, together with assessment of sensation, hair growth, and the development of contracture was performed by an independent clinician. Thirty-four (16%) of 214 palm burns that presented to our institution during this period required grafting, of which 26 (77%) agreed to participate in this study. At a mean 13.5 months postsurgery, pliability was significantly enhanced in FTSG compared with SSG (P < .001). Although not statistically significant, vascularity and height of SSGs were preferred. There was no difference in sensation between the two types of graft or donor site outcomes, although hair growth was significantly (P = .002) more prominent in FTSG. There were an equal number of contractures in the two groups, with grafts of either type that extended from the palm onto the volar aspect of digits more commonly affected. These data suggest an improved outcome in children with deep palm burns after FTSG, although with the exception of scar pliability these differences were small.

Pediatric Palm Contact Burns: A Ten-Year Review

Management and proper approach to pediatric palm burns remains unclear. Our burn center's approach includes early, aggressive range of motion therapy, combined with a period of watchful waiting, reserving grafting only for those palms that do not heal in a timely manner. We reviewed our experience using this approach over a 10-year period. We performed a retrospective review of all pediatric patients with palm burns admitted to our burn center from 1994 to 2004. A total of 168 patients (194 palms) were included in the study. The average patient was 1.3 years old. A total of 168 of the injured palms (87%) healed without need for surgery. The average time to healing was 13 days (range 5-34). The 19 patients (26 palms, 13.4%) who underwent excision and grafting were managed with thick split thickness skin grafts. Of these, four patients (five palms, 19.2%) underwent secondary reconstruction, at an average of 166 days after the initial surgery. Of the 168 (87%) palms managed without surgery, only three patients (four palms) required late reconstruction (2.4%). Reconstructive procedures consisted of full-thickness skin grafts (n = 7) and z-plasty (n = 2). We have found that the majority of patients in this study healed without need for acute or reconstructive surgery. We therefore recommend aggressive hand therapy and conservative surgical management of palm burns in children.

Incorrect Acticoat application causing iatrogenic injury to a child with a palmar burn

Acticoat (Smith and Nephew, Melbourne, Vic., Australia) is a nanocrystaline silver dressing which has broad spectrum antimicrobial and anti-inflammatory actions. This dressing must first be moistened with sterile water to become effective. Acticoat has been shown to significantly reduce the need for skin grafting in children with partial thickness burns and we recommend its use in the ED setting. Iatrogenic injury caused by the incorrect application of Acticoat to palmar burns is seen frequently in our Burns Clinic. This letter highlights a recent case and we provide recommendations for the prevention of this injury. A 9-month-old boy presented to the Royal Children’s Hospital Outpatient Burns Clinic, Melbourne, Australia, 3 days after sustaining a partial thickness contact burn to his left palm. The initial injury was confined to the hypothenar eminence. He was first seen in an ED where Acticoat was applied (Fig. 1). Saturated circumferential applications of Acticoat and an overlying plastic wrap resulted in maceration of the entire hand and interdigital shearing (Fig. 2). To protect non-injured skin when dressing hand burns with Acticoat, we recommend that: 1. Acticoat should be moistened with sterile water, but not dripping wet. 2. Acticoat and overlying occlusive dressings should not extend further than 1 cm beyond burn margins (Fig. 3). 3. Digits must first be separated before the hand is bandaged (Fig. 4). EDs play a vital role in treating the vast majority of partial thickness burn injuries. Knowledge of the

Early Serial Casting for Palmar Burns to Prevent Contractures

Palmar burn injuries cause scar contracture in patients requiring long term therapy and contracture release to achieve optimal outcome. Serial casting is employed at many burn centers as a method of preventing and correcting scar contractures, particularly at the elbow. At our regional burn center, we have used early serial casting for palmar burns to prevent palmar contractures. We have retrospectively reviewed the records of 64 patients with palmar burns requiring skin grafts (full and split thickness) admitted in the time period between Jan. 1999-Jan. 2005. Each of these patients underwent skin grafting and serial casting, with a long or short arm cast, and most patients were casted from the date of grafting until the graft was healed and the hypertrophic scar had started to mature. 64 patients, ages 5 months to 72 years, mean 9.8 years, underwent serial casting for palmar burns. Our population consisted of 21 females and...

Contact palm burns in toddlers from glass enclosed fireplaces.

We have seen an alarming increase in the incidence of pediatric palm burns associated with gas fireplaces. The increasing popularity of these units places more children at risk. Medical records of patients under the age of 5 years who sustained hand burns from contact with the glass enclosure of gas fireplaces from 1996 through 2002 were reviewed. Thirty-nine patients were identified, with a mean age of 12.8 months. A 15-fold increase in incidence was observed. Thirty-three patients suffered superficial second-degree burns that were treated conservatively. Twenty-one percent of children developed significant wound complications requiring intensive therapy including extension splinting or surgery. Pediatric burns resulting from palmar contact with the glass enclosures of gas fireplaces have emerged as an avoidable new danger within the home. Although most of these injuries heal with conservative treatment alone, many require surgery or other intensive management to regain acceptable function.

Results of early excision and full-thickness grafting of deep palm burns in children.

The timing and method of treatment of deep palm and finger burns varies widely. Our protocol involves performing full-thickness skin grafts (FTSG) in nonhealing palm burns. We reviewed the functional and cosmetic results after FTSG to the palm. From August 1997 to April 1999, 11 patients (12 palms) underwent excision and FTSG within 2 weeks of injury. A panel of medical and nonmedical professionals evaluated follow-up pictures of the grafts at 1, 2 to 4, and beyond 4 months. Parameters used for evaluation were color match with the unburned skin (1 = no difference to 4 = large difference), graft thickness (1 = flat to 4 = markedly raised), overall appearance (1 = poor to 100 = excellent), and time to maturity. Hand function, as assessed by occupational therapy notes, was also recorded. All 12 grafted palms had a 100% take and healed with minimal scarring. Mean color match scores were 2.4 at 1 month, 1.8 at 2 to 4 months, and 1.6 beyond 4 months. On the graft thickness scale, grafts were given scores of 2.6, 2.2, and 1.9 during the same intervals. The overall appearance was 71 at 1 month, 81 at 2 to 4 months, and 85 beyond 4 months. All grafts except 1 were judged to be mature at 2 to 4 months follow-up. Full passive range of motion was attained in all grafted hands within the period of 2 to 4 months after operation. Early excision and FTSG of deep pediatric palm burns can be performed in the outpatient setting. The grafts have an acceptable color match, are minimally raised, and achieve excellent cosmetic result. The grafts mature within a few months after surgery to allow for rapid return to normal range of motion. FTSG should be considered as a first choice for deep palm burns.

The isolated burned palm in children: epidemiology and long-term sequelae.

The isolated burn of the palm is a typical injury in young children. Positioning and splinting in small hands is difficult, and long-term sequelae of these injuries are not uncommon. The objective of the present study was to assess the outcome of palm burns and to identify the risk factors for long-term sequelae. All patients admitted to our hospital affected with isolated palm injuries between January of 1988 and January of 1998 were reviewed. In total, 120 pediatric patients were admitted with isolated palm burns; 110 patients (91.7 percent) had partial-thickness burns, and 10 patients (8.3 percent) had full-thickness burns. Only four patients (3.3 percent) required excision and skin autografting, but all patients whose palms were operated on in the acute phase developed burn contractures. Sixteen patients (13.3 percent) developed palmar contractures, and more than half of them (56 percent) required reconstructive procedures. All palm burns that healed in more than 3 weeks developed scarring and sequelae (p<0.05 compared with no sequelae). Pediatric palmar burns are benign injuries with a low incidence of late sequelae. However, flame and contact burns are more prone to develop scarring. Excision and autografting should be performed on wounds that take over 3 weeks to heal, but it does not prevent late sequelae.

Treatment of recurrent digital scar contracture in paediatric patients by proximal phalangeal island flap

Despite adequate medical treatment, digital palmar burn scar contractures can still occur in children. Surgical treatment basically consists of scar release and skin grafting or Z-plasty. However, recurrence of deformity can occur, especially in children. Ten children with recurrent digital contractures were operated. The palmar scars were released and the defects covered by proximal phalangeal island flap. All flaps survived completely and no recurrence was observed, even 5 years after surgery. These promising results encouraged us to propose proximal phalangeal island flap as first choice in the treatment of recurrent digital scar contractures in paediatric patients.

A simple and compressive splint for palmar skin grafting in young children with burns

A simple, compressive, and easily applied splint which is suitable even for fearful and uncooperative patients after skin grafting for paediatric deep palmar burns is described. The hand, including the wrist and the forearm, is inserted between the palmar and dorsal plates of the splint and thus compression and immobilization act to decrease flexion contracture and dysfunction of the digits. Compression can be easily controlled by the use of leather bands.